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Job Objective: A brief overview of the position.
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The professional in this role position has primary responsibility for coordination of projects related to organizational and regulatory requirements, including The Joint Commission, California Department of Public Health, the Centers for Medicare and Medicaid Services, and other accreditation and certification entities. In addition, this role provides administrative support to the Director of Quality Improvement and Patient Safety Officer, Infection Preventionists (IP), and other Patient Safety and Quality Improvement staff.
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Reports to
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- Quality Manager or Director
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Supervises
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N/A
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Ages of Patients
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N/A
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Blood Borne Pathogens
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Minimal/ No Potential
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Qualifications
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Education
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Required: Bachelor degree
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Licensure/Certification
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N/A
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Experience
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Required: 5 years recent professional business experience; 2 years in coordinating multiple complex projects and working with information technology
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Preferred: Healthcare experience in similar role.
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Essential Responsibilities
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Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
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Manages administrative duties for Director of Quality Improvement and Patient Safety Officer, Quality Managers and Quality Improvement and Patient Safety staff.
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Manages all hospital system licensure requests, de-licensing, hospital annual license, and other requests as needed.
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Manages the triage process for quality of care and service concerns received from internal or external entities in written and/or verbal complaints, and involves appropriate leadership staff in Service Recovery, as necessary.
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Liaison for phone communication with Quality Improvement staff, physicians, patients, families and in-house contacts.
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Responsible for mail daily, attaching appropriate reference materials when pertinent and forwarding to appropriate recipient.
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Responsible for establishing/maintaining effective files for Director of Quality Improvement and Patient Safety Officer, and Quality Manager, including personnel records.
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Demonstrates positive professional and interpersonal behavior with all levels of management, staff, medical staff, and public, as necessary.
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Works with QI Staff to prepare and maintain current reports and documentation for Joint Commission, CDPH, and CMS Continued Survey Preparedness, including managing the process to maintain updates and review documentation related to regulatory compliance.
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Enters Surgical Site infection Works with Infections Preservationist to manage data entry processes for NHSN (CDC mandatory reporting site) accurately and to meet deadlines from CDC, completes reporting forms for Public Health, reports infections data to regulatory bodies, maintains spreadsheets and internal tracking with graphs for IP Committee and Quality Council IPs. Sends out questionnaires to surgeons quarterly to query surgical site infections, and other duties as needed.
- Performs other duties as assigned.
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Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
